Another World Aids Day is behind us and the usual spatter of annual reports and politicians’ eager promises continue to reverberate through the media. If you’re like me, you’re probably tired of the whole show at this point. After all, it’s 2012, we were supposed to have this epidemic licked by now. Why, despite billions of dollars’ worth of interventions and three decades of high-profile messaging, does Aids remain such a pressing problem?

This is particularly puzzling in the case of southern Africa, where close to 20% of the adult population carries HIV. In Swaziland, where I am from, the figure reaches 42% in antenatal clinics. These numbers are shocking in any context, but in light of the massive prevention effort that has been underway since the 1980s they truly boggle the mind. Clearly something isn’t working in our battle against Aids.

The anti-Aids effort is failing because it fundamentally misperceives the problem. It starts from the assumption that the Aids burden reflects a culture of sexual promiscuity, moral depravity and basic ignorance among Africans. This is why the primary Aids programmes — the World Bank, UNAIDS and most NGOs — peddle “awareness” and “behaviour change” as the frontline solutions.

Not only does this narrative carry obvious racist undertones, it’s also just not true: southern Africans are not ignorant about HIV/Aids. In fact, stats show that most of them are highly knowledgeable about it, and often know more than their Western counterparts. The problem is that this knowledge doesn’t translate into behaviour change. A recent study shows that awareness “changes the behaviour of, at most, one in four people — generally those who are more affluent”. In other words, “behaviour change” programmes are failing at a rate of 3 to 1.

This disparity tells us a lot. Wealthy people respond to awareness campaigns because their participation in risky sexual behaviour is voluntary. Not so with the poor. For them, risky sexual behaviour is generally compelled by structural factors beyond their control. In southern Africa, poor people are often forced to pursue labour migration and engage in transactional sex just to make a living. These are the key drivers of HIV transmission.

We need a new way to approach the problem. Instead of targeting sexual behaviour, we need to target the conditions under which sexual behaviour occurs. That’s where the true pathology lies. In southern Africa, this means shifting the blame from the victims of Aids to a specific set of powerful actors who have rigged the regional economy for their own benefit and subjected millions of people to conditions that facilitate the spread of HIV. Aids is not a disease, it’s a symptom — a symptom of an unjust global order.

The labour migration system
One reason that southern Africa has higher HIV rates than other poor regions is that it is shaped by a unique system of rotating migration. During the colonial era, European capitalists needed a steady supply of cheap black workers for their mines, plantations and factories. To get it, they restricted Africans’ access to arable land and imposed taxes to force them onto the labour market. But Europeans didn’t want African workers to settle permanently in urban areas. Instead, they ferried workers in on a temporary basis and then sent them back to the “native reserves” when they were used up.

The rotating migration system allowed Europeans to rake in huge profits. Companies could pay migrant workers much less than what permanent urbanites required to support their families, since the difference was covered by unpaid subsistence activities in the reserves. This system continues to this day: for instance, unskilled workers in South Africa come from as far afield as Malawi and return home as infrequently as once a year.

When HIV hit the continent in the early 1980s it spread rapidly through these migration networks. It was an epidemic waiting to happen. In South Africa, HIV prevalence is nearly three times higher among migrant workers than among non-migrants. Migration increases high-risk sexual behaviour among men who are away for long periods of time, and this increases HIV prevalence among their female partners tenfold.

These high prevalence rates have to do with the conditions that characterise migrant destinations, like mines and plantations. These are zones of hyper-exploitation: high injury rates, depression and loneliness among workers mixed with the steady supply of alcohol and prostitutes that managers dish out to suppress dissent encourages unsafe sex. Poor healthcare services in these zones means that even easily curable STIs go untreated, which makes HIV transmission up to 400% more likely. This is why the highest prevalence rates in the world are found at migrant workplaces, sometimes reaching as high as 70%.

If people know about these risks, then why migrate in the first place? The short answer is that they usually have no choice. Remittances sent home by migrants are critical to household survival, and many households have no other source of income; they cannot afford to forfeit such staple earnings in favour of geographical solidarity. When families are forcibly strung across the subcontinent, “abstinence” and “fidelity” — the values promoted by HIV prevention campaigns — become impossible ideals for both men and women.

Rules imposed by the West
The colonial system severely constrained Africans’ livelihood options, but the new order of capitalism has gone much further. Beginning in 1980 the IMF and the World Bank imposed free-market shock therapy on African economies in line with neoliberal principles. They did this through “structural adjustment programmes” that cut spending on services like healthcare, privatised public assets and cut trade tariffs (a major source of revenue for poor countries) in order to pry open new markets and create “investment opportunities” for Western companies. They also raised interest rates to keep inflation low so that the value of debts to the West would not diminish, even though this hampered governments’ ability to spur growth.

We were told that structural adjustment would generate development. Quite the opposite. While sub-Saharan Africa enjoyed a steady per capita growth rate of 1.6% during the 1960s and 70s, beginning in the 1980s growth began to fall at a rate of 0.7% a year. The average GNP shrank by about 10% under structural adjustment, and the number of Africans living in basic poverty nearly doubled. Inequality has soared to unprecedented rates, enriching corrupt local elites (consider the rapid rise of South Africa’s black bourgeoisie) at the expense of a growing underclass.

These policies have been particularly rough on rural farmers. The abolition of price controls, subsidies and tariffs have all made it harder for farmers to make a living. In addition, free-trade rules have allowed big agribusinesses, often foreign-owned, to capture vast swathes of the region’s best farmland. As a result, farmers are forced to move to urban slums in search of better fortunes. But since there’s no formal employment available in the cities anymore they can’t afford to live there permanently, so they migrate back and forth. It’s like colonialism 2.0.

Sex for money
The other key driver of HIV transmission in southern Africa is transactional sex: when women exchange sex for money. Most Aids gurus talk about transactional sex as if it were a choice that women make or they cast African men as sexual predators. But it’s not that simple. Women engage in transactional sex with wealthier men because they lack access to the resources they need to live. This often entails relinquishing control over the terms of sexual intercourse, such as condom use.

Given these conditions, campaigns that focus on awareness promotion among women have precious little effect. Report after report concludes that increased knowledge does not assist women to avoid risky sexual behaviour: their financial desperation is grave enough to outweigh concerns about their own health. In other words, women are willing to risk one health threat (HIV) in order to stave off another, more immediate one (hunger).

Women who secure formal employment feel less pressure to engage in transactional sex, but such employment is almost impossible to find. Structural adjustment decimated employment levels by exposing infant industries to crushing competition and jacking up interest rates. Unemployment now sits at close to 40% in much of the region — far worse than before Western banks showed up with their promise of “development”.

The World Trade Organisation (WTO) joined the attack on African economies at its inception in 1995, and has directly contributed to the region’s Aids burden. For example, Swaziland’s once-thriving textile industry was flattened in 2005 when the WTO liberalised the global textile trade. Factories shut down overnight as producers relocated to Asia for cheaper labour, putting some 30 000 women instantly out of work. Many of these women turned to transactional sex to fill the breach, and the fight against Aids suffered a monumental setback.

Life-saving medicines
One of the most troubling things about the Aids epidemic is that it could have been stopped so easily by rolling out life-saving antiretroviral drugs (ARVs) early on. Not only do ARVs prevent HIV from developing into Aids, they also reduce transmission rates and increase people’s willingness to get tested.

But Western pharmaceutical corporations have colluded in pricing these essential drugs way out of reach of the poor. When they were first introduced, patented ARVs cost up to $15 000 per yearly regimen. Generic producers were able to manufacture the same drugs for a mere fraction of the price, but the WTO outlawed this through the 1995 Trade-Related Aspects of International Property Rights (Trips) agreement to protect Big Pharma’s monopoly.

It was not until 2003 that the WTO bowed to activist pressure and allowed southern Africa to import generics, but by then it was too late — HIV prevalence had already reached devastating proportions. In other words, much of the region’s Aids burden can be directly attributed to the WTO’s rules and the corporations that defended them. And they are set to strike again: the WTO will cut patent exemptions for poor countries after 2016.

This dearth of basic drugs has gone hand in hand with the general collapse of public-health institutions. Structural adjustment and WTO trade policies have forced states to cut spending on hospitals and staff in order to repay odious debts to the West. Swaziland, ground-zero in the world of Aids, has been hit hard by these cuts. When I last visited I found that many once-bustling clinics are now empty and dilapidated. Neoliberalism has systematically destroyed the first line of defence against Aids.

The point I want to drive home is that the policies that deny poor people access to life-saving drugs and destroy public healthcare come from the same institutions and interests that helped create the conditions for HIV transmission in the first place.

Shifting the blame
In light of all this, the rhetoric of “individual responsibility”, “behaviour change” and “moral depravity” that defines Aids discourse begins to seem quite absurd. Let’s be frank: it is not the culture of African peasants and workers that is morally depraved, but the culture of institutions like the WTO and the IMF. Economist Joseph Stiglitz has exposed these institutions as some of the most corrupt and anti-democratic in the world, run by a cabal of elite corporate interests.

The forced neoliberalisation of Africa was not just blind devotion to economic ideals that turned out not to work. It was intended to create crisis and debt. Western states, banks and corporations have made off with trillions of dollars from privatisation, mineral extraction, cheap labour and debt service — a net flow of wealth from poor countries to rich countries that vastly outstrips the meagre aid that trickles the other direction.

If anyone needs a dose of behaviour change, it’s the institutions that have orchestrated this heist. The Aids epidemic is a symptom of the crisis they have caused and it will rage on as long as the plunder continues.

If we’re to be serious about rolling back Aids, we need a new approach. We need to release poor countries from structural adjustment so they can rebuild their economies using tariffs, subsidies, state spending and low interest rates — the very policies that rich countries use. We need to cancel odious debts so poor countries can spend money on health services instead of interest payments. We need to amend Trips to decommoditise life-saving drugs. And we need to tweak the WTO’s Agreement on Agriculture to ban the dumping of subsidised farm products on poor countries. This means reforming the World Bank, the IMF and the WTO, where voting power is monopolised by rich nations and special interests.

The World Bank and the Gates Foundation — the biggest funders of Aids prevention — cannot be entrusted with these tasks, as they have clear interests in the very policies (debt service, structural adjustment and patent laws) that have created the problem in the first place.

In sum, battling Aids means challenging the power of rich nations over the world’s resources, it means creating a world in which economic policies are democratically ratified and where capital is harnessed to benefit humanity rather than the other way around. The Aids crisis provides an extraordinary opportunity to do this. With more than one million deaths due to Aids in southern Africa alone each year, never has there been a more powerful mandate to interrogate the tenets of neoliberal capitalism.

Note: This article originally appeared in Al Jazeera. The argument is made with full data and citations here. Click here to view the academic article where these findings are fully documented.

It needs to be debated by civil society and decided how we can act on it.

Don’t rely on the politicians. We the people have to understand these underlying economic issues and do something to change the balance of power: “it means creating a world in which economic policies are democratically ratified and where capital is harnessed to benefit humanity rather than the other way around.”

Thanks Jason Hickel. Very good article.

Qunu

Great socialist thinking – and I believe it has good intentions. However like all trendy lefty thinking, which abuses those dreadful capitalists and Western people – you may want to consider how much human rights feature in other societies – communist countries, religious dictatorships, and African tribalist systems. Sorry, but so much trendy rhetoric is just that – trendy but shallow. Lightweight.

I have a choice, keep my penis in my pants or use it. I am not thinking about the latest IMF agreement, or how much cash I have earned in the past 12 months when I make that decision.

Knowing that I have a 25% chance of dying if I have sex with a woman I barely know is enough to stop me from doing it. Knowing that I could infect and kill my wife afterwards is double reason not to.

Sorry, we all have the basic responsiblity to look after our own lives.

Removing that responsibility from the person on the street, and passing it to any number of faceless organisations is going to do more damage to the fight against Aids than raising the price of ARVs.

EVERYONE needs to take responsibility.

Ouch

Thank you for a logical, easy to read and well constructed article. I lived in Swaziland and saw the devastation by AIDs on the people there. Many of my work team are now deceased. Our lovely office cleaner is deceased. Weekend participation in social events by Swazi staff was impossible because of funerals. I can see the pain and loneliness of the compound labour force working for contractors and ultimately for big business.

I would like to think if I knew what I know now, I would have done something braver. Reality is I probably wouldn’t have. In our non poverty lives we still have pressures that most of us give in to. Family needs/wants/aspirations; peer group pressure; fear of rejection by our community/employer.

This fear goes all the way up to merchant bankers.

Isn’t debt – period – the ultimate cause. Maybe the anti-ursury bunch have a point.

Cde Fanny Mabuso

The ANC, DA and Mamphele Ramphele are all neo-liberal capitalists. They are all part of the problem, not part of the solution.

Only the newly formed Workers and Socialist Party (WASP) to be launched in March this year have the balls to take on the neo-liberal world order and stop migrant work in South Africa.

That is what I think.

Otherwise long live HIV-AIDS and a host of other social ills we currently experience.

We need a more equal society, a smaller gini co-efficient, or gap between super rich and super-poor.

Momma Cyndi

If HIV is a result of poverty then why are WE at the top of the list? Not like we are a hell of a lot poorer than Bosnia or Somalia. It isn’t even about migrant labour or Zimbabwe would be top of the totem pole.

HIV awareness programs worked in Europe and America. It isn’t about them thinking we are all dumbassed darkeys in Africa, it is because they cannot understand that something that works there won’t work here. Its arrogant but hardly ‘racist’.

As much as I dislike the idea that life saving medication is not completely free of charge, I also understand that it takes a hell of a lot of money to develop, test and release those medicines. Not having the possibility of making up for the millions of ‘failed’ drug formulations or the possibility of making a profit, the drugs would never be developed. Sad reflection of human nature but its the way we are

Maria

Jason, I wish all politicians around the world would read your piece, as it unravels the connecting threads between neoliberal capital, hell-bent on profit, no matter what, and AIDS in a compelling manner. Why anyone would think that people in SA cannot understand the link between (unprotected) sex and HIV, and that it’s therefore a simple matter of “abstinence,” I find mind-boggling. Unfortunately few people grasp the connections between the structural economic factors you uncover so well, on the one hand, and the persistence of high HIV infection rates, on the other. Just as in the 19th century under colonial capitalism, the drivers of the system today do not care a fig for impoverished workers; in fact, poverty plays right into their hands, for the more impoverished people there are crying out for some meager income, the more they are assured of labor that they can exploit to the hilt.

Alois

My concerns are more immediate. I would like behaviourists to give us some understanding of what is fueling the rash of crimes against humankind in the form of gang rape violence. That is not to suggest, in any way, that a single gang rape is “an acceptable alternative.” I even wonder did the so-called caveman so behave? Is this behaviour common in human events? After all, the counjtries where the most prominent cases have taken place are countries ostensibly in a state peace and not war. Finally, are we entering the Hobbesian world?

“If HIV is a result of poverty then why are WE at the top of the list?”

You should read the article again. Read about the impact of migrant labor versus secure full-time employment on HIV/AIDS. You appear to have missed the main thrust of the article.

Also understand the economic system that underlies migrant labor. Migrant labor is modern day slavery. I know right wingers will argue against that but so be it.

Perry Curling-Hope

Urbanisation is a phenomenon of all human societies, not a consequence of ‘neoliberalism’, and predates such by a few centuries,
With urbanisation comes migrant labour, which is not a consequence of ‘rules imposed by the West’

As for ‘structural adjustment’, if you don’t like the terms, don’t borrow the money.

There is this persistent notion that should a loan be offered and one cannot dictate the terms thereof. that one is being ‘exploited’
Likewise, if employment is offered and one doesn’t get to dictate the wage or other terms one desires or believes to be appropriate that one is again being ‘exploited’

Not every problem humans face is political, public servants are not omnipotent gods, and some things are not amenable to their machinations or being fixed if only the right ‘policies’ were to prevail.

Poverty, ‘inequality’ and disease have ‘plagued’ humanity for….a really long time, but the overall human condition continues to improve along these metrics despite the grumbling of naysayers

Momma Cyndi

Cde Fanny Mabuso

You should read the rest of my comment AND look up the definition of the term ‘slave’.

Tofolux

@Jason, can I add to the ”new approach” is to challenge capitalism. I say this especially because not only does capitalism continues to create and maintain this unequal society, but also because it entrenches the crass materialism and greed of the Americanised economy. In any case, the above challenges together with poverty will continue and get worse under capitalism. I will put that the new approach of the new emerging economies is the light at the end of the tunnel. Most of the countries who are prospering are those who have mixed economies. Also, I am personally hoping that China becomes the No 1 economy in the world much faster than expected. This will certainly challenge the monopoly America has over the world economy and it we can only challenge the dollar, the playing field is on its way to tilted in favour of Africa. BTW, China’s record of developmental aid as opposed to America’s strategy of impoverishing Africa is obvious. The time must come where the super-rich or overclass in America must stop using Africa and our resources in their monopoly game. The only reason why poor people cannot overcome Aids is simple economics.

http://necrofiles.blogspot.com Garg Unzola

Is this article for real? More of the Klein-like hysteria with its shoddy research and unsubstantiated claims. AIDS is a serious matter and to blame the lack of treatment thereof on Neo-Liberalism is short-sighted and misinformed. Recall that the Neoliberal Capitalists were all too keen to give AIDS medicine away to South Africa, but that Dr Beetroot and others prevented them from doing so. Botswana accepted being ‘exploited’ by big pharma and subsequently also handled their AIDS epidemic much better than RSA did.

If anyone cites Naomi Klein, by now I just assume they have no idea what they are talking about. Klein has been debunked and exposed as a fraud, time and again.

Cde Fanny Mabuso

@Momma Cyndi

You say “AND look up the definition of the term ‘slave’.

“One who is abjectly subservient to a specified person or influence: “I was still the slave of education and prejudice” (Edward Gibbon).”

AND that supports what I said – “Migrant labor is modern day slavery.” i.e abjectly subservient to neo-liberal capitalism.

Momma Cyndi

Cde Fanny Mabuso

Yea, not so sure that poetry is now considered a dictionary.

Cde Fanny Mabuso

@Tofolux

The ANC are croney capitalists, that is the most dishonest type of capitalism. Not even the Americans are croney capitalists of the order of the ANC. Even the DA are purer more honest capitalists than the ANC. The Chinese are also croney capitalists or state capitalists.

You are either a true socialist or you are with the ANC and other neo-liberal capitalists.

Tofolux

@C fanny, hurling mindless insults is counter-productive and adds no value to the debate. Also,as we learn we must be prepared to subject ourselves and learn from those who are not only exposed to better information but also because they speak from personal experiences. As we learn to become better human beings, we are humbled partly with information to better help those around us. Jason articulates something wich many sobre thinking persons would agree on. Ie the effect of capitalism on diseases of the poor but in particular HIV/AIDS. I dont know if you have noticed that we are dealing with a pandemic which is on the same scale as other infectious diseases such as ebola etc and in dealing with these challenges how do we as a country respond? Clearly the subject matter is not serious enough for you to be constructive and helpful. The flip side however is that if you were infected/ affected etc would your response be better considered. Capitalism in America is a scourge that is visited on African countries. We experience the roll-on effect of this greed and the resulting poverty which has plagued our continent first hand. If we as the resource-rich but money-poor and them as money-rich but resource-poor think that we hold any leverage against capitalism, then clearly we are clueless about financial systems and crises. But then again, if this is over the head for u I understnd noting the knee-jerk anti-ANC defence mechanism which exposes a certain lack or incapacity.

http://necrofiles.blogspot.com Garg Unzola

The beautiful thing about the truth is it does not rely on how many people agree with it. In fact, something can still be true even if nobody agrees with it. or know about it.

In South Africa’s case, the AIDS epidemic has very little to do with capitalism since our health care is tightly controlled by public policy and we had the option of accepting AIDS aid free of charge and mahala. Our AIDS policies are a clear case of government (that is ANC) failure.

For those who don’t have ideologically tainted minds, there’s a good chunk of Bad Science dedicated entirely to South Africa’s policy failures regarding HIV. I would recommend this book to anyone who still believe in the neat, plausible and wrong analyses. In other words, to anyone who still uses the term Neoliberal.

Tofolux

@Garg, the inference is made on Africa as a continent. If Aids has killed so many people on our continent how many could have been saved (on our Continent) if the Pharmaceutical companies had come to our rescue much earlier. In fact, your narrow-minded allegation against the ANC is quite lunatic considering that they have very little say on the health policies of WHO or AU (duh). So can you move from the laager and think BIG PICTURE “AFRICA” maybe and ask yourself the obvious questions around the role and relevance of a pro-poor, progressive pharmaceutical industry?

Tofolux

Oh and GaArrrgg, hint “PHILANTHROPIC”?

http://maravi.blogspot.com/ MrK

@ Momma Cyndi

“If HIV is a result of poverty then why are WE at the top of the list?”

Because South Africa is where the money is.

You see it used to be Uganda, back in the 1990s, but then it became clear that the ‘30% infection rate’ didn’t translate in even a slowing population growth. The population grew by 3% per year, and it was clear they were not decimated by anything, let alone HIV/AIDS. This was around 1998.

So by 2000, they moved on to South Africa.

HIV/AIDS in Africa has been characterised by corporate profiteering, and the use of bad surveys and bad testing procedures to crank up the national HIV prevalence estimates.

What they do is 1) use pregnant women at antenatal clinics and 2) use only a single ELISA test for confirming whether a sample is positive or negative. That is how you get ‘30% of Swazis are HIV positive’, etc. Zambia’s national HIV prevalence rate is still based on the use of pregnant women.

However, the DRC’s prevalence rate is listed as 1.3%, in their 2007 DHS (google: measuredhs).

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Having spent the first half of his life in Swaziland, Jason earned a doctorate at the University of Virginia and now holds a fellowship at the London School of Economics. His research focuses on development, globalisation and labor, with an emphasis on Southern Africa. He lives in constant fear of being sniffed out for his counter-revolutionary penchant for bourgeois wine and jazz. Follow him on Twitter @jasonhickel.